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Sterek, Appendix 2
image:Starfleet Medical.png FILE ACCESS RESTRICTED TO COMMANDING OFFICER, CHIEF MEDICAL OFFICER AND SECURITY CLEARANCE LEVEL 3 AND ABOVE PLEASE ENTER CREDENTIALS BELOW ---- image:Starfleet Medical.png DATE AND TIME: 237204.15, 0324h FACILITY: USS Nightingale, Medico-Forensic lab Reasons for admittance Patient was admitted as per standard procedure following successful extraction from hostage situation during which time he was subjected to torture and allowed inadequate access to food, water and hygiene facilities. History Patient is a Vulcan male, 43 solar years of age, no existing medical conditions prior to capture. Examination Patient appears malnourished, dehydrated, and sleep-deprived, with various visible injuries and noticeable difficulty walking. Preliminary scans at triage showed no immediate life-threatening conditions and initial assessment showed that patient was compos mentis and able to consent to examination (Appendix: Scan A, Recording 1). Secondary scans revealed numerous contusions, lacerations, fractures and burns, both internal and external (Appendix: Scan B.) Of particular note are the following: * Linear fractures to right superorbital margin extending to zygomatic bone * Type 2 nasal fracture with mild epistaxis on examination * Extensive skin abrasions on right cheek with early signs of infection (see: specimens: sample 1) * Point of left ear completely severed at base of sagittal helix (patient unable to preseve the severed tissue) * Tissue damage consistent with recent lateral jaw subluxation and linear maxillary fractures (patient is a medical professional and reports attempting to treat his own injuries during incarceration) * Oesophagal and superficial molar corrosion consistent with repeated vomiting and starvation * Contact electrical burns on right and left side of both ventral and dorsal thoracic-cervical region (Appendix: Scan B, Detail) with swelling and discharge consistent with bacterial infection (specimens: sample 2) * Nine fractured ribs (Appendix: Scan B, Detail) including 1 on right-hand side and 1 and 2 on left-hand-side (ventral) * Tissue damage consistent with dislocation and relocation of right shoulder (relocated by patient) * Second, third and forth fingernails of right hand completely detached * Transverse fracture of left humerus and ulna * Comminuted fractures of left manual phalanges and metacarpals consistent with crushing * Extensive abdominal and lumbar bruising * Internal and external injuries consistent with repeated sexual assault (Appendix: Scan B, Detail; specimens: SAECK kit & forms) * Stable fracture of left tibia * Fifth pedal metatarsal avulsion fracture * Comminuted fractures of forth and fifth pedal phalanges consistent with crushing No difficulties or limitations encountered during examination. Patient avoids eye contact but speech and behaviour is consistent with his cultural norms. He is able to explain most of his injuries but reports several periods of time that he cannot recall. Traumatic amnesia is common in Vulcans and neurological scans show no evidence of brain injury so this is not a point of concern. Management Patient agreed to light sedation and pain relief on arrival but has refused further sedatives. Recommend that emergency rehydration, parenteral nutrition, clotting agents and infection control measures are administered prior to advanced tissue regeneration program, and that patient is referred to our crisis psychiatric team immediately. While he was able to give a calm and detailed report of his injuries (Appendix: Recording 2), caution is advised regarding further questioning as a delayed reaction to trauma is not uncommon. It is highly recommended that his attending psychologist is consulted before any attempt is made to interview the patient or collect further forensic evidence. The patient has been advised to avoid telepathic contact with others until a specialist has been consulted.